History Taking

General sheet / Information Gathering

Hello Mr. …. Sit down please. I am …(position)…

Personal history Name – Age – Occupation

Complaint PainSwelling / Ulcer – Dysfunction – Others

History of present complaint Analysis

Other symptoms Relation to the main complaint

What is the problem? ….

Tell me more about that.

Tell me more about ….  What about ….?  Do you have ….?

History of present investigations and treatment

 

Systematic direct questions

I’m now going to ask you a series of questions about common medical problems.

This to make sure we do not mess anything that may be important.

  • CVS

Do you have any trouble with your heart, chest pain or palpitation?

  • Respiratory

Do you have any trouble with your lungs, shortness of breath, coughing or sputum?

  • GIT

Do you have problem in digestion, lose weight, difficulty in swallowing, heart burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal bleeding?

  • Genitourinary

Do you have any problems passing urine, change of color, pain, smell?

  • Diabetes Mellitus
  • Female

Do you have problems in menstruation?

Past history

Have you been admitted to any hospital before?

Did you have any operation before?

Do you have children? How many? How old is the youngest? (Female)

Do you take any medication or contraceptive pills (Female)?

Do you have any allergy?

Family history

Do you have any similar problem in your family (children, parents, brothers, sisters)?

Does anyone of your family have a heart disease, DM, blood pressure, tumor or any chronic disease?

Social history

Do you smoke? That do you smoke? How much? For how long?

Do you drink? How much/week?

Patient concern 

Are you concerned about anything?

Summery 

To summarise …. (+ve. findings)

Ulcer – History

Ulcer Analysis

  • Site (where is it?)
  • Onset (sudden or gradual?)
  • Course (does it increase or decrease in size with the time?)
  • Duration (when did it appears?)
  • Other swellings (do you have other swellings?)
  • Relation to other symptoms like pain or swellings
  • Possible Cause(why do you think you’ve got it?)
  • Constitutional symptoms (did you become feverish?)

Swelling – History

Swelling analysis

  • Site (where is it?)
  • Onset (sudden or gradual?)
  • Course (does it increase or decrease in size with the time?)
  • Duration (when did it appears?)
  • Other swellings (do you have other swellings?)
  • Relation to other symptoms like pain (is it painful?)
  • Possible Cause (why do you think you’ve got it?)

Pain – History

Pain analysis

  • Site & referral (where is it? Where it goes?)
  • Onset (sudden or gradual?)
  • Course (how often does it happen?)
  • Duration (when did it start?)
  • Severity (how bad is it?)
  • Character (Burning, throbbing, stabbing, constricting, tightness, colicky or just a pain) (what does it feel like?)
  • Relieving factors (what eases it?)
  • Exacerbating factors (what brings it?)
  • Cause like trauma (why do you think you’ve got it?)